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症例は74歳の女性. 右卵巣嚢腫, 胆嚢ポリープの診断で経過観察中. 平成6年8月28日, 腹部超音波検査で脾に径20×20mmの低エコー病変を認めた. 症状はとくに無く病変も小さいことから経過観察とした. 10月9日再検で脾病変は38×45mmと増大していたため, 精査を勧めたが本人の希望で経過観察とした. 左側腹部痛が出現したため12月12日当院受診, 再検で腫瘍は68×67mmと更に増大していた. 腹部CT, 腹部血管造影, 67Gaシンチグラフィーなどの画像診断から脾原発悪性リンパ腫を疑い, リンパ節郭清を伴う脾摘出術を施行した. 病理組織学的所見はmalignant lymphoma, diffuse lymphomalarge cell typeと診断された.術後化学療法は行っていないが, 3年を経過した現在, 再発の兆候なく経過観察中である.

A 53-year-old man was admitted to the hospital because of left flank dull pain. Abdominal US revealed a dilatation of the pelvis of the left kidney. DIP showed left non-function kidney and CT combined DIP revealed air density in the dilated pelvis. When percutaneous pelvic drainage was conducted, pus discharge was observed, and a catheterography performed at that time visualized that a contrast material entered the descending colon. We diagnosed the case as renocolic fistula. Pus discharge and high grade fever persisted and so a lapalotomy was performed 5 days after drainage. Left nephrectomy and partial resection of the colon were performed. A histological study revealed squamous cell carcinoma, grade 1, INFα, pT (colon), pR0, pL0, pV0. It has been reported that squamous cell carcinoma of the renal pelvis grows invasively. This case in which the carenoma directly invaded the colon to form fistula is very rare.

A 63-year-old woman was admitted to the hospital because of hematochezia. Severe anemia and thrombocytopenia were noted (red blood cell 248×104/mm3, hemoglobin 5.8g/dl, hematocrit 19.6%, platelet count 0.8×104/mm3). The patient was diagnosed as sigmoid colon cancer associating with idiopathic thrombocytopenic purpura (ITP). Transfusion of 25 units of platelet was performed and a large dose of globulin 20g/day for 5 days, methylprednisolon 500-1000mg/day, and prednisolone 50mg/day were administered. When the platelet count increased to 25.2×104/mm3, splenectomy and sigmoidectomy with lymphnode dissection (D2) were carried out. After the surgery, abnormal bleeding did not occur and the postoperative course was uneventful. After discharge, the patient has been followed at outpatient clinic as of 6 month after the operation, and the plateletcount is kept at good level of 25.2×104/mm3 without taking predonisolone.The large dose gulobulin regimen appears an extremely safe and useful method in preoperative management of surgical patients with ITP. It is possible to keep increased platelet level by splenectomy.

We report a case of intussusception at Braun's anastomosis occurring 10 years after gastrectomy. The patient was a 52-year-old man who had a history of gastrectomy for gastric cancer. The main complaints were severe abdominal pain and vomiting with acute onset. From the result of UGI, US and CT, his illness was diagnosed as intussusception of the jejunum, and laparotomy was performed 13 hours after admission. The findings of laparotomy showed that partial gastrectomy by the antecolic Billroth II method with Braun's anastomosis had already been performed, and the efferent jejunal loop was found to be intussuscepted retrogradely through the Braun's anastomoisis 12cm from the anal side, and then via the efferent loop into the jejunogastric anastomosis. The reduced jejunum was not injured by manual reduction, and its color was good, so resection was not performed, and the efferent loop was fixed. It was not very difficult to diagnose this disease because of its characteristic patterns in the preoperative examinations. In the diagnosis of upper abdominal pain after gastrectomy, we have to take this disease careful consideration.